HomeMy WebLinkAbout14969 (20)CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS -4 ! DDS /'l /C .d
APN LOT TRACT
OWNER 1L�0
ADDRESS S�1 Mme,
CITY ZIP TEL -
APPLICANT TEL -
CONTRACTOR LCONTRACTOR
ADDRESS
CITY ZIP 4W-e_rt-TELL r�<'
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DESIGNER
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION _
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LL
CENSE LAW FOR THE FOLLOWING REASON (SEG TM1.5 "NESS AND PROFESSIONS CODE ANY CITY OR
COUNTY WHICH REOLARESA PERMIT TO CONSTRUCT, ALTER IMPROVE. DEMOLISH, OR REPAIR ANYSTRUC-
YUAF_ PRIOR TO ITS ISSUANCE ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U.
CENSE LAW (CHAPTER N (COMMENCING WITH SECTION 7000) OF DIVISION 7 OF THE BUSINESS AND PRO.
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7051.5 BY ANYAPPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS CSSOMI: - -
O L AS OWNEROF THE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEG 7044, BUSI-
NESS AND PROFESSIONS CODE- THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BULDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
TRP40LCM HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF. HOWEVER. THE BULDINO OR IMPROVEMENT IS SOLD WITHINONE YEAR OFCOMPL&
- TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE)
O L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTNO LVITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC 7044. BUSINESS AND PigFFSSKNS CODE: THE CONTRACTORS Ll•
CENSE LAW DOESNOTAPPLY TO AN OWNER OF A PROPERTY WHO SURDS OR IMPROVE$ THEREON, AND
WNDCONMCTS FOR SUCH PROAECTS WITH AOONTRACTOR(S) LICENSED PURSUANT TO TME CONTRAC-
TORS LICENSE LAW.).
❑ IAM EXEMPT UNDER SEG B. S P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HERESY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER
0 (WNO WITH SECTION 700DIVISION 7 OF THE BUSINESS AND PROFESSIONS CODE.0) OF DAND
W UCPNSE IS N FULL FORCE AND EFFECT. �( /
LICENSE GU LIC. NO.
DATE CONTRACTOR
- - - - WORKERS' COMPENSATION DECLARATI N ..
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWNO DECLARATIONS:
_ I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKE" COMPENSATION INSURANCE, AS REQUIRED BY SECTION -
5700 OF THE LABOR CODE FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. W WORKERS' OOMPFNSATION INSURANCE CARRIER AND POLICY NUMB FIR ARE:
CARRIER
POLICY NUMBER
"9M NEED NOTBECd.REfEDOFTHE PFAM17IS PORMIEHLMMM DOLLARS' IOMORLESSI
I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I
- - -- SNALLNOT EMPLOYANY PERSON IMAM MANNER SO AS TO PECOME SUBJECT TO THE
WOHKERSCOMPENSATION LAWSOF CALIFORNIA, AND AOR ATff ISHOIAO BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS FS . 77000, THE LABOR
CODE, ALL TH COMPLY WITH THOSE P 5
DATE: d0 , APPLICANT
WARNING. FALURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (7100.000)• N ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
SECTION 7708 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
1 HEREBYAFFIRLI UNDER PENALTYOF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FORTHE PERFORMANCE OF THE WORK FOR WHICH THIS PEPM17 IS ISSUED (SEG 5097, CIV. C.).
LENDERS NAME - -
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CRY AND COUNTY ORDINANCES Al. STATE LAWS RELATING TO BUILDING
CONSTRUCTXW.ANOHEREBYAUTHORIZEREP . SFNTATNESOFTHISCOLNTYTOENTIFIII.THE
ABOVE-MENTIONED PRIOPERTY FOR INS PE RPOSES.
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TUBE OF PERMITTEE
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